Periacetabular osteotomy: an analysis of social media to determine the most common questions asked by the periacetabular osteotomy population

Background The Bernese Periacetabular Osteotomy (PAO) has become a popular surgery for fixing development dysplasia of the hip, yet the most common concerns of the PAO population remains ambiguous. The aim of this study was to investigate Facebook, Instagram and Twitter to further understand what the most common preoperative and postoperative questions patients undergoing PAO are asking. We hypothesized most questions would be asked by patients in the preoperative timeframe with regards to education surrounding PAO surgery. Methods Facebook, Instagram and Twitter were queried consecutively from February 1, 2023 to November 23, 2011. Facebook was searched for the two most populated interest groups; “Periacetabular Osteotomy (PAO)” and “Periacetabular Osteotomy Australia”. Instagram and Twitter were queried for the most popular hashtags: “#PAOwarrior”, “#PAOsurgery”, “#periacetabularosteotomy”, “#periacetabularosteotomyrecovery”, and “#paorecovery”. Patient questions were categorized according to preoperative and postoperative questions. Questions were further placed into specific themes in their respective preoperative or postoperative question types. Results Two thousand five hundred and fifty-nine posts were collected, with 849 (33%) posts containing 966 questions. Of the 966 questions, 443 (45.9%) and 523 (54.1%) were preoperative and postoperative questions, respectively. The majority of questions were postoperative complication related (23%) and symptom management (21%). Other postoperative questions included recovery/rehabilitation (21%), and general postoperative questions (18%). The most common preoperative questions were related to PAO education (23%). Rehabilitation (19%), hip dysplasia education (17%), and surgeon selection (12%) were other preoperative questions topics included. Most questions came from Facebook posts. Of 1,054 Facebook posts, 76% were either preoperative or postoperative questions and from the perspective of the patient (87%). Conclusion The majority of patients in the PAO population sought advice on postoperative complications and symptom management. Some patients asked about education surrounding PAO surgery. Understanding the most common concerns and questions patients have can help providers educate patients and focus on more patient-relevant perioperative conversations.


Background
Social media is becoming a valuable resource for patients, physicians, and other healthcare professions.Facebook groups and hashtags connect patients with others that are interested or experiencing similar problems.Patients are using social media to seek information, support, or share experiences outside their physician's office.Social media sites such as Facebook, Instagram, and Twitter may give physicians an unprecedented view of patients' unsolicited attitudes towards their experiences [1-4, 7, 14-18].
The Bernese Periacetabular Osteotomy (PAO) is used to treat symptomatic hip dysplasia with good longterm outcomes [12,13,21,22].The PAO is frequently performed in adolescent and young adult cohorts [9], although studies have proven adults over the age of 40 can have good outcomes following PAO [9,13].Given the younger average age of PAO patients [9], and the significantly higher rates of social media use in younger patients (18-29 years old) when compared to older patients [15], social media may be a useful tool to further explore the patient PAO experience.
In other populations, such as hip arthroscopy, total knee arthroplasty, scoliosis, medial patellofemoral ligament, and breast reconstruction, social media has been used to investigate patient-perceived experiences, outcomes, and concerns utilizing a thematic categorization methodology [1,7,11,14,16,20].Yet, to our knowledge, little is known about what patients undergoing a PAO are most concerned with and what the most common questions on social media are for this patient population.The aim of this study was to investigate common questions and concerns voiced on social media by the PAO population.Understanding the most common preoperative and postoperative questions can help providers better educate, treat, and support patients.A previous study found limited medical information on the internet surrounding PAO [19]; therefore, we hypothesized most questions would be asked by patients in the preoperative timeframe with regards to education surrounding PAO surgery.

Data collection
Posts were collected from Facebook, Instagram, and Twitter.For Facebook, 1,054 posts were collected from two separate Facebook groups: "Periacetabular Osteotomy (PAO)" (948 posts) and "Periacetabular Osteotomy Australia" (106 posts).For Instagram and Twitter, the hashtags #PAOwarrior, #hipdysplasia, and #periacetabularosteotomy were used to collect posts.There were 1,003 and 502 unique posts collected from Instagram and Twitter, respectively.Post collection began on February 1, 2023, and collected sequentially through November 18, 2021, June 16, 2021, and November 23, 2011, when 1,000 unique posts were collected for Facebook, Instagram, and Twitter, respectively.Twitter only had 502 posts using the hashtags previously listed.Posts unrelated to PAOs or hip dysplasia were recorded but did not count towards the total posts.

Data categorization
Collected posts were given a sequential number, one being the most recent post on February 1, 2023.A thematic analysis methodology was utilized for all posts.Seventeen thematic categories were created.These categories included: social media site, media format (text, video, picture), post perspective (patient, physician, family/friend, hospital or physical therapy group, professional organization, news media, industry), sex (female, male, unknown), race, timing of post (preoperative, postoperative, perioperative), content, complication, preoperative question, postoperative question, post-op time-frame, concomitant surgery, number of likes, number of comments, and number of shares.
Pre-operative and post-operative questions were coded as shown on Table 1.Posts that contained questions in the period before a patient had surgery were categorized as "Pre-operative Question, " while posts that included questions after a patient underwent surgery were designated as "Post-operative Question." Posts entered within the "General post-operative questions" subcategory included, but were not limited to, questions relating to scar appearance, concomitant surgeries, common concerns and questions patients have can help providers educate patients and focus on more patientrelevant perioperative conversations.health insurance, and recommendations for appropriate attire.Posts without questions spanned a variety of topics including activities of daily living, recovery progress, patient outcomes, and words of encouragement or support, among additional topics.Posts that were unrelated to PAO or hip dysplasia were counted but were categorized as "unrelated." Additionally, other authors each categorized 20 posts to limit the variance in the subjective interpretation of posts (90.0%inter-observer agreement when analyzing question categorization).

Analysis
Coding in to separate thematic categories allowed us to quantitatively analyze qualitative data.The data was analyzed using Microsoft Excel.

Results
Of the 2,559 posts collected, 1,054 were from Facebook, 1,003 were from Instagram, and 502 were from Twitter.Each social media site had authors that posted multiple times.The top five posters from Instagram, Facebook, and Twitter accounted for 21%, 9%, and 29% of the posts, respectively.87% of posts were from patients, and 6% were from either a family member or friend.Females authored 84.8%, 96.6%, and 84.9% of posts collected from Instagram, Facebook, and Twitter, respectively (Table 2).
Out of the 392 posts in the preoperative period, 443 (45.9%) questions were analyzed.A majority of the preoperative questions related to education surrounding the PAO surgery (23%).Other popular preoperative questions asked were rehabilitation (19%), hip dysplasia education (17%), surgeon selection (12%), and preoperative pain (11%) (Table 4).The vast majority of these preoperative questions still came from Facebook (414, 93.45%); however, Instagram was found to be more likely to contain preoperative questions(n = 15) compared to postoperative questions (n = 12).Examples of both a preoperative and postoperative question are found in Fig. 1.

Discussion
The use of social media by patients to obtain medical guidance has benefits and risks.For patients, it allows communication with fellow patients that are in the same situation and can provide support [17].Social media   can also provide a means of educating patients of their own health affairs [17].Prior studies have shown that healthcare organizations tend to use social media for supplying information to general audiences, providing content regarding their organization, increasing public relations, and promoting overall well-being [2].Formal patient reported outcome measures and physical exam findings have long been used to track patient outcomes and patient satisfaction [21,22].However, social media is now popular and may be used to gain insight into patients' true feelings and perspectives that could be missed in clinic.Patients may feel they can be more of their true self on social media [17].However, a potentially serious pitfall of social media is the spread of misinformation from one patient to others.Social media can satisfy the unmet need for reliable medical information and advice that patients are seeking in the perioperative period.Potential exists for social media to partner with the healthcare community for vetted, reliable healthcare information through patient testimonials.Patients in these communities are looking for more than percentages and facts.We have found that patients are often trying to validate their own specific experience.
Patients asked significantly more questions on Facebook than they did on Instagram and Twitter, suggesting that Facebook groups may be a more convenient way of gathering information quickly on a topic.Thus, future studies analyzing the content of the comments may be needed to appreciate the accuracy or relevance of the answers to the questions.A majority of the questions were associated with complications and symptom management of complications, specifically acute and chronic pain and questioned if what they felt was similar to others' experience.Physicians and healthcare providers should further emphasize the importance of directly contacting medical providers for concerns in the preoperative and post-operative period.
Questions regarding rehabilitation were asked 19% and 21% of the time preoperatively and postoperatively, respectively, suggesting that this aspect of PAO is an important concern for patients.Given that the average patient undergoing PAO is an adolescent or young adult [9], it logically follows that increased emphasis is placed on rehabilitation and restoration of full hip health, allowing patients lead more active, fulfilling lifestyles.Questions ranged from specific physical therapists to work with postoperatively, rehabilitation supplies such as walkers and other durable medical equipment, to different stretches and exercises that helped other patients' recovery and symptoms.Prior studies have shown the standardization of rehabilitative care following PAO is essential for achieving optimal outcomes despite other factors such as geographical location and socioeconomic status [5].Connecting with physical therapists that specialize in PAO or developmental dysplasia of the hip (DDH) rehabilitation through use of social media or virtually could be a great opportunity for improving outcomes and marketing physical therapy services.Therefore, creating virtual appointments and instructional rehabilitation videos online could increase outreach to the PAO population.
Surgeon selection was commonly asked about preoperatively, which suggests that patients strongly value other patient's perceptions of surgeons.While prior studies have shown that most patients employ Google, there still is a large proportion of patients that utilize social media for surgeon selection [6].Although it is important for patients to be able to express their opinions, this creates an opportunity for surgeons to accurately reflect their credentials and patient-reported outcomes online to help patients make an informed decision.
Prior studies have shown social media can be used to increase accessibility to health information [10,17].The data presented here demonstrated that education about PAO and hip dysplasia accounted for a total of 40% of the preoperative questions asked by the patient population.Educational topics included but were not limited to: duration of surgery, what screws were used, X-ray interpretation, DDH evaluations, and indications regarding concurrent labral repair with their PAO.The significant amount of educational questions surrounding PAO and DDH suggest an inadequate amount of educational guidance available to patients and highlights the need for easily accessible and accurate information.With increased social media use among certified professionals, we can decrease the disconnect between information currently available with common questions and concerns patients are asking online.
This study is limited by the selection bias that comes through the use of social media.Not everyone that undergoes PAO surgery posts on social media, therefore our results may not be generalizable for the entire PAO population [1].Additionally, social media users tend to emphasize positive aspects of their subject, potentially introducing a positive bias and inadvertently excluding the voices of patients with negative experiences of PAO surgery [8].Second, the subjective nature of patient's questions and concerns may not be directly correlated with the PAO surgery itself.Furthermore, this study was limited by sampling bias in that although this study contains a total of 2,559 posts, which was large enough to have a representative sample for analysis, the sample size might not be reflective of the actual PAO general population.This largely stems from only being granted access to two of the three most populated private PAO Facebook groups, along with not being able to access private posts within Instagram or Twitter.Lastly, there is interobserver variation in interpretation of posts.To mitigate this error, we included a twenty-post review by other authors to ensure that posts were graded in a consistent manner.

Conclusion
Patients and family members of the PAO population generally asked postoperative questions that related to complications, such as non-union, infection, allergic reactions, as well as symptoms, such as chronic postoperative pain and nerve pain.Preoperatively, patients and family members were mainly concerned with education surrounding the PAO surgery.Facebook was found to be the best social media site to determine what questions and concerns patients undergoing PAO are asking.Instagram, Facebook, and Twitter continue to be resources for patients that may include medical advice and guidance from non-medical personnel.Finally, future studies comparing questions asked by patients in clinical settings, rather than social media, may allow us to better understand the gaps in knowledge surrounding PAO.

Fig. 1 (
Fig. 1 (A) Sample post of a preoperative question from Facebook (PAO education).(B) Sample post of postoperative question from Facebook (Symptom management)

Table 1
Preoperative and postoperative question categories

Table 2
Baseline characteristics of social media authors

Table 3
Postoperative question content summary

Table 4
Preoperative question content summary